New MA Codes, Supplemental Benefits Could Improve Dementia Care

September 13, 2019

An estimated 5.5 million older Americans are living with Alzheimer’s disease, and this figure is expected to jump to 14 million by 2060 — but it is believed that Alzheimer’s and other forms of dementia in the U.S. are still largely underdiagnosed. With the addition of two new codes to the Medicare Advantage risk adjustment payment system and expanding flexibility in MA benefit design, Alzheimer’s advocates are hopeful that such changes will lead to increased diagnoses, improved treatment and greater awareness of clinical trials for disease-modifying therapies.

Starting Jan. 1, 2020, CMS will incorporate into its risk score calculation for MA plans an alternative payment condition count (APCC) model that includes additional Hierarchical Condition Category (HCC) codes for dementia: HCC51 — Dementia With Complications and HCC52 — Dementia Without Complications. Plans will therefore have a financial incentive to capture the appropriate diagnosis codes, and by assigning equal weights to the two codes, CMS has minimized the chance of upcoding, observes Catherine Murphy-Barron, a principal and consulting actuary with Milliman.

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An estimated 5.5 million older Americans are living with Alzheimer’s disease, and this figure is expected to jump to 14 million by 2060 — but it is believed that Alzheimer’s and other forms of dementia in the U.S. are still largely underdiagnosed. With the addition of two new codes to the Medicare Advantage risk adjustment payment system and expanding flexibility in MA benefit design, Alzheimer’s advocates are hopeful that such changes will lead to increased diagnoses, improved treatment and greater awareness of clinical trials for disease-modifying therapies.
Starting Jan. 1, 2020, CMS will incorporate into its risk score calculation for MA plans an alternative payment condition count (APCC) model that includes additional Hierarchical Condition Category (HCC) codes for dementia: HCC51 — Dementia With Complications and HCC52 — Dementia Without Complications. Plans will therefore have a financial incentive to capture the appropriate diagnosis codes, and by assigning equal weights to the two codes, CMS has minimized the chance of upcoding, observes Catherine Murphy-Barron, a principal and consulting actuary with Milliman.

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Health Plans Wait for More Data on New Narcolepsy Medicines

with Chart: Current Market Access to Narcolepsy Medications

September 12, 2019

Two newly approved narcolepsy medications offer novel, possibly more effective options to people for whom older medications aren’t working well, but most plans are requiring patients and providers to try generic alternatives first.

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Two newly approved narcolepsy medications offer novel, possibly more effective options to people for whom older medications aren’t working well, but most plans are requiring patients and providers to try generic alternatives first.

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Part D Redesign May Not Hit Plan Sponsors Too Hard

with Chart: Effects of Part D Redesign Proposals Vary by Payer

September 12, 2019

While some of the options on the table for redesigning Medicare Part D would place a lot more financial risk onto plan sponsors, there are reasons to believe that the consequences of such a shift might not be that severe.

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While some of the options on the table for redesigning Medicare Part D would place a lot more financial risk onto plan sponsors, there are reasons to believe that the consequences of such a shift might not be that severe.

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Magellan Touts Adherence in Specialty One-on-One Coaching

September 12, 2019

Magellan Rx Management says that members who use its MRx Specialty Pharmacy are significantly more likely to reach and maintain adherence goals of 85% or greater, in large part due to motivational coaching from nurses. But one industry expert says he would want to see more data before reaching conclusions about the program’s effectiveness.

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Magellan Rx Management says that members who use its MRx Specialty Pharmacy are significantly more likely to reach and maintain adherence goals of 85% or greater, in large part due to motivational coaching from nurses. But one industry expert says he would want to see more data before reaching conclusions about the program’s effectiveness.

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News Briefs

September 12, 2019

✦ Thus far in 2019, 33 states have enacted a record 51 laws to address drug prices, affordability and access — beating the previous record of 45 laws enacted in 28 states set last year. That’s according to a Kaiser Health News (KHN) article citing data from the National Academy for State Health Policy, which notes that the measures include ones that establish drug-price oversight boards, authorize importing prescription drugs and ban “gag clauses” in PBM contracts. “Both Democrat and Republican leaders have shown a willingness to pursue strong measures that help consumers but also protect state taxpayer dollars,” Hemi Tewarson, director of the National Governors Association’s health programs, told KHN. Read more at https://bit.ly/2kzHcfn.

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✦ Thus far in 2019, 33 states have enacted a record 51 laws to address drug prices, affordability and access — beating the previous record of 45 laws enacted in 28 states set last year. That’s according to a Kaiser Health News (KHN) article citing data from the National Academy for State Health Policy, which notes that the measures include ones that establish drug-price oversight boards, authorize importing prescription drugs and ban “gag clauses” in PBM contracts. “Both Democrat and Republican leaders have shown a willingness to pursue strong measures that help consumers but also protect state taxpayer dollars,” Hemi Tewarson, director of the National Governors Association’s health programs, told KHN. Read more at https://bit.ly/2kzHcfn.

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